Preferred Member Agreement/AutoShip/Order Form - Shop - Waiora

Preferred Member Agreement/AutoShip/Order Form
To become a Preferred Member visit us at www.waiora.com, or you may fax this completed form. If you apply by phone you must send
the application to us within 10 days or the agreement will be void. Send to: Waiora at 7835 NW Beacon Square Blvd., Boca Raton, FL 33487
Phone 1-866-MY-WAIORA (1-866-699-2467) • Fax 1-561-922-2197
Preferred Member Information
Name (Last, First, Middle Initial) or Business Name Area Code Daytime Phone Number
Street Address (Current Mailing Address)
City
State Zip Code E-mail Address
Referred By
Birth Date (MM/DD/YY)
Distributor # or Federal Tax ID #
Name (Last, First, Middle Initial)
Area Code Daytime Phone Number E-mail Address
AutoShip / Order Information
When selecting your product or pack, please refer to the price list posted online.
Be sure to check "New AutoShip" if you'd like to make this a recurring monthly order.
Please check which one of the following apply:
New AutoShip
Change my AutoShip
This is not an AutoShip
An AutoShip allows you to receive Waiora product automatically every month. The AutoShip Program selection is included on this application for your
convenience. By selecting AutoShip you authorize the company to automatically ship your monthly order, and collect the appropriate funds each month.
Please supply ALL required information. Orders are subject to the local sales tax of your region and will be added to your order total. Shipping & handling
charges will also be added. AutoShip orders are billed each month coinciding with your monthly order date.
Note: Your first order will be processed upon approval of this application, and subsequent orders will fall into the regular AutoShip billing & shipping
schedule beginning the following month.
Item # Description Price Qty Total Cost
Sales Tax
Sales tax, where applicable, is calculated on the retail price. (If you have any questions on
whether sales tax is applicable in your area, please contact your Waiora Support Group.)
Shipping & Handling
Shipping is 5.75% of the subtotal or a minimum of $5.95.
Subtotal
+ Sales Tax
+ Shipping & Handling
= Overall Total
By signing below to become a lifetime Waiora Preferred Member, I understand there is a one time application fee of $9.95
Payment Information
❍ Check # ___________________ ___ ❍ Mastercard ® ❍ Visa ® ❍ Discover ® ❍ American Express ®
Credit Card Security Code (3 or 4 digits) Authorization Signature
Cardholder’s Name (Last, First, Middle Initial)
I have read and agreed to the terms of the AutoShip Agreement on the reverse side of this document, and am familiar with the Waiora refund policy found in
the policies and procedures and agree with the terms and conditions, which by reference are fully incorporated into this agreement (if applicable).
Expiration Date (MM/YY)
Applicant Signature
Today’s Date (MM/DD/YY)
All faxed copies may be deemed as originals.
Item # 13512 0710

WAIORA ® AUTOSHIP AGREEMENT
TERMS AND CONDITIONS. PLEASE READ THOROUGHLY. As a participant in the Waiora AutoShip program, I authorize Waiora
USA, Inc. (“Waiora”) to ship my order to me monthly after processing the payment method that I have indicated. Waiora is
under no obligation to ship any products until full payment has been received. Shipment will take place approximately two
days from payment confirmation.
1. ADVANTAGESHIP: All new AutoShip Agreements received will generate an order to be shipped within two days of receipt.
Each month thereafter your AutoShip order will be sent on or about the same time each month. Orders received between
the 21st and end of month will be sent on or about the 20th of each month.
2. SHIPPING AND HANDLING: All AutoShip orders are shipping via ground shipping. Shipping and handling charges applied to
each AutoShip order are as follows: 5.75% of the order subtotal with a minimum of $5.95.
3. REVISION: You may revise your AutoShip Agreement monthly. To do so, submit a Preferred Member AutoShip Agreement
and check the box labeled Change my AutoShip or modify your agreement online by visiting www.waiora.com. The AutoShip
Department must have revisions no later than 10 business days prior to your next AutoShip shipment date. If the revision is
received less than 10 business days prior to shipment, there will be no guarantee that the revision will be effective for that
shipment. The revised application will be in effect for the next shipment date.
4. CANCELLATION: If a Preferred Member decides to cancel the AutoShip program, a signed notification must be submitted
to the AutoShip Department or the cancellation must be done online. The AutoShip Department must have cancellation
notice no later than 10 business days prior to your next AutoShip shipment date. If the cancellation is received less than 10
business days prior to shipment, there will be no guarantee that the order will not ship.
5. RETURNS: As a customer of Waiora, you are entitled to receive a refund of 100% of the product purchase price within 30
days of purchase. Prior to any product being returned to Wairoa, a Return Merchandise Authorization (RMA) Number must
be issued. Please contact the Waiora Support Team to receive an RMA by calling 1-866-MY-WAIORA (1-866-699-2467).